In June 2013, a woman known only as Patient B was in the back of an ambulance being raced to Sydney's St George Hospital as she bled uncontrollably following uterine surgery.
She had just come out of elective surgery at a private hospital, but while in recovery, her condition deteriorated. She needed 12 units of blood and to be resuscitated.
The doctor who had agreed to take over her care at St George Hospital suggested that given her case had become critical, she would be better sent to the emergency department at Royal Prince Alfred Hospital, which was significantly closer.
But instead, the doctor in the ambulance beside her, Peter Petros, claimed they were already on their way to St George. Once there, Dr Petros failed to tell treating physicians the woman had just undergone a new treatment.
She had been fitted with a Tissue Fixation System (TFS), commonly known as transvaginal mesh, which Dr Petros himself invented and which he and his family had a significant financial interest in.
The woman, who cannot be identified for legal reasons, had actually sustained a major arterial bleed during the new procedure and spent the next four weeks in hospital.
But the doctors who took over this critical patient's care were not made aware of some key measures doctors had already taken to manage her bleeding.
They were also working under an assumption that she had undergone a more typical procedure used to treat vaginal prolapse, known as a sacrocolpopexy.
It is for these reasons Dr Petros has been the subject of a damning ruling by the NSW Civil and Administrative Tribunal after a case was brought by the Health Care Complaints Commission.
The tribunal found the surgeon, who has practised in Western Australia and New South Wales, guilty of professional misconduct.
One expert for the tribunal found the experienced gynaecologist's handover to his colleague at St George Hospital "was significantly below the standard expected".
However, because Dr Petros is now retired, he will not face any official sanctions.
The tribunal found that if Dr Petros, now aged 78, was still registered, his registration would have been cancelled and he would have been disqualified for being a doctor for two years.
During the case, Dr Petros denied his handover explanation at St George Hospital was inadequate.
Petros failed to tell patients his device was no longer approved
The tribunal heard the case of Patient B was not the only reason authorities had concerns about Dr Petros's behaviour.
As recently as November 2014, Australia's regulator of medical devices, the Therapeutic Goods Administration, cancelled the registration of Dr Petros's TFS device.
But despite being aware his product was no longer approved for the use, he failed to tell nine patients who had the device implanted between November that year and February 2015.
Dr Petros was a surgical assistant in those procedures but took control in two cases.
It further found that between 2013 and 2014, Dr Petros failed to tell 113 patients who had surgery with the TFS device about his or his family's financial interest in the product.
Dr Petros has been credited as an inventor of one of the first mesh devices, which paved the way for similar products to explode onto the market.
While for some women the products have been able to successfully treat incontinence and prolapse following childbirth, for many it has led to crippling chronic pain and associated medical conditions.
It has been the subject of a Senate inquiry in Australia, class actions, and has been banned in some countries.
The cases have also exposed serious flaws in the way medical devices make their way onto the market after the original design that led to the TFS was only tested on 13 large dogs while he was working in Perth.
Bittersweet victory for all mesh victims
For women like Perth mother-of-three Tracey Whyte, the tribunal's decision brings an end to one of many campaigns to achieve justice for victims of surgical mesh.
Ms Whyte has been crippled for two decades since having a TFS device implanted to treat mild incontinence when she was just 35. She was not a patient of Dr Petros.
Now aged 55, she has had to give up many activities in her life after having five types of mesh implanted inside her.
"I woke up with five different meshes inside me. I was immediately sick. I literally went to bed for four years," she said. "I wasn't told there'd be any complications. I was just told I'd have a little bit of tape around my bladder."
She now lives with chronic pain, has extreme difficulty urinating and said her health has been on a "constant downhill slide" since then.
"I had an entrapped clitoral nerve which no-one can really explain unless they're living with it."
She said women in her support group had been experiencing a range of emotions from anger to complete loss and sadness following the tribunal's decision.
"We thought here you go, someone's going to be held accountable, but it didn't really turn out that way.
"I'm just happy someone finally has been brought to task."
Ms Whyte was particularly critical of the time it took medical authorities to act on many fronts.
"When you look at the damage that was being done to women and seemingly being completely ignored, it just doesn't seem right that it wasn't investigated or wasn't brought into the light way before that."
She was also concerned about some of the financial arrangements exposed during the case. "It just goes to show the corruption that is endemic and surrounds mesh," she said.
"It's just a boys' club of denial."
Ms Whyte said the decision reinforces the need for the federal government to act quickly to enact the recommendations of the Senate inquiry into the scandal.
"The only way they can stop this is to make further legislation."
Ms Whyte is also part of legal action against medical practitioners involved in her case.